Cord management in the delivery room: from physiological principles to clinical practice

Umbilical cord management is a critical determinant of cardiovascular transition at birth. Placental transfusion during the first minutes of life contributes substantially to neonatal circulating blood volume, ventricular preload, and haemodynamic stability. Early cord clamping, once routine, interrupts this physiological process and is increasingly recognised as non–evidence based, particularly in preterm infants. Accumulating clinical and experimental data demonstrate that delayed cord clamping improves haematological indices across gestational ages and reduces mortality and major morbidities, including severe intraventricular haemorrhage, in preterm neonates without increasing maternal risk. In parallel, alternative strategies have emerged to address situations in which delayed clamping is perceived as impractical. Umbilical cord milking can rapidly augment neonatal blood volume but has been associated with haemodynamic instability and an increased risk of severe intraventricular haemorrhage in extremely preterm infants, leading to cautionary recommendations against its use in this population. More recently, physiology-based cord clamping approaches, which align cord clamping with the establishment of effective lung ventilation, have shifted the focus from time-based to event-based transition, aiming to preserve cardiac output and cerebral perfusion. Despite substantial progress, important uncertainties remain regarding optimal implementation, applicability in compromised neonates, and feasibility in diverse delivery settings. In this Review, we synthesise physiological principles, clinical trial evidence, and emerging data on delayed cord clamping, umbilical cord milking, and physiology-based cord clamping. We propose a mechanistic framework for cord management that prioritises haemodynamic stability and supports an optimal transition from fetal to neonatal life.